Munster Med-Inn

Based on observation, record review, and interview, the facility failed to ensure professional standards of quality were maintained related to CNAs removing dressings to pressure ulcers for 1 of 5 residents reviewed for pressure ulcers. (Resident P)Finding includes: On 1/28/26 at 11:54 a.m., the Wound Nurse was observed providing wound care for Resident P. She prepared the supplies outside of the resident's room and donned a gown and gloves prior to entering. Upon entering the room, the resident was positioned on her left side and there was no dressing to the sacrum (a triangular bone at the base of the spine). CNA 5 was in the room at that time, she indicated she had just provided incontinence care and she removed the dressing because it was soiled. The Wound Nurse proceeded to treat the area to the sacrum. The record for Resident P was reviewed on 1/23/26 at 10:45 a.m. Diagnoses included, but were not limited to, type 2 diabetes, need for assistance with personal care, anxiety, and stage 4 pressure ulcer of the sacral region (skin breakdown that involves full-thickness tissue loss…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure an ongoing activity program was implemented for cognitively impaired and dependent residents for 2 of 2 residents reviewed for activities. (Residents 2 and K)Findings include: 1. On 1/22/26 at 9:34 a.m. and 1:39 p.m., Resident 2 was observed in his room in bed with his eyes open and his television turned on. On 1/23/26 at 10:40 a.m. and 2:30 p.m., the resident remained in his room in bed with his television turned on. The record for Resident 2 was reviewed on 1/27/26 at 9:15 a.m. Diagnoses included, but were not limited to, bone and prostate cancer, vascular dementia with mood disturbance, stroke, and major depressive disorder. The Annual Minimum Data Set (MDS) assessment, dated 8/21/25, indicated the resident had moderate cognitive impairment and music and animals such as pets were very important to him. The Quarterly MDS assessment, dated 11/6/25, indicated the resident remained moderately impaired for daily decision making and he had little interest or pleasure in doing things. He was also dependent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and interview, the facility failed to ensure interventions were in place and the correct treatment was provided for 2 of 4 residents reviewed for pressure ulcers. (Residents T and U)Findings Include:1.On 1/27/26 at 10:15 a.m., Resident T's wound care was observed with the Wound Nurse. The resident was positioned on his left side in his bed. There was a small pressure ulcer, approximately 0.5 centimeter long on his sacrum. The nurse cleansed the area with normal saline and gauze, patted it dry, then applied a hydrocolloid dressing to cover the wound.The resident's record was reviewed on 1/22/26 at 9:40 a.m. Diagnoses included, but were not limited to, fracture of the left humerus and cellulitis of the left lower extremity.The admission Minimum Data Set (MDS) assessment, dated 12/1/25, indicated the resident had moderate cognitive impairment and needed partial/moderate assist with bed mobility and transfers. A Physician's Order, dated 12/19/25, indicated to cleanse the sacrum with normal saline and/ or wound cleanser, apply skin prep to the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and interview the facility failed to provide adequate supervision for a resident with swallowing precautions and failed to keep sharp objects out of a resident's room who resided on the memory care unit for 2 of 6 residents reviewed for accidents. (Residents M and 1)Findings include: 1. During a random observation on 1/21/26 at 9:12 a.m. Resident M was observed in bed eating breakfast. The resident was served eggs and some type of ground meat. The meal ticket indicated supervision with meals, no straws, and to check mouth after solids. The resident should be upright during the meal and to take small bites and alternate solids and liquids. The resident had a straw in his water cup. There was no staff in the room while he was eating. During a random observation 1/23/26 at 8:17 a.m., the resident was observed in bed eating his breakfast. He was served two scoops of scrambled eggs, a bowl of oatmeal and two pieces of toast. He was served a cup of thickened orange juice and carton of thickened milk. The resident was observed feeding himself with no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and interview the facility failed to ensure a resident received the correct diet as ordered for 1 of 4 residents reviewed for nutrition. (Resident 16)Finding includes:On 1/20/26 at 12:10 p.m., Resident 16 was observed in bed in his room. A staff member entered the room and brought his lunch tray. He asked for it to be set on the table for later. The lunch was a slice of meatloaf, one scoop of mashed potatoes with gravy and vegetable. The tray ticket indicated Heart Healthy diet, double portions. At 12:17 p.m., LPN 4 observed the lunch tray and ticket and indicated it was not double portion.The resident's record was reviewed on 1/22/26 at 1:16 p.m. Diagnoses included, but were not limited to, diabetes mellitus and dependence on renal dialysis.The Quarterly Minimum Data Set assessment, dated 12/4/25, indicated the resident was cognitively intact and needed set up assist for eating. A Physician's Order, dated 11/10/25, indicated CKD (Renal) diet, regular texture. There was no order for double portions. During an interview on 1/22/26 at 1:34 p.m., the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure the residents' oxygen was set at the correct flow rate for 2 of 2 residents reviewed for oxygen. (Residents M and X)Findings include: 1. During a random observation on 1/20/26 at 12:41 p.m., Resident M was observed in bed wearing oxygen via nasal cannula. At that time, the oxygen flow rate was set at 0.5 liters per minute. During a random observation on 1/21/26 at 9:12 a.m., the resident was observed in bed wearing oxygen via nasal cannula. At that time, the oxygen flow rate was set at 1 liter per minute. The record for Resident M was reviewed on 1/23/26 at 11:05 a.m Diagnoses included, but were not limited to, stroke, monoplegia of upper limb affecting right side, dysphagia (difficulty swallowing), COPD, chronic respiratory failure, major depressive disorder, dementia, and heart failure. The 12/2/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision received oxygen while a resident. A Care Plan, revised on 12/12/25, indicated the resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure a scheduled pain medication was available and administered as ordered for 1 of 4 residents reviewed for pressure ulcers. (Resident F)Finding includes:Resident F's closed record was reviewed on 1/21/26 at 2:15 p.m. Diagnoses included, but were not limited to, diabetes mellitus, repeated falls, and unspecified protein calorie malnutrition.The Quarterly Minimum Data Set assessment, dated 11/17/25, indicated the resident was cognitively intact and had a stage 3 (full-thickness skin injury appearing as a deep crater where subcutaneous fat is visible, but muscle, tendon, or bone are not exposed) pressure ulcer.The Pain Care Plan, dated 6/19/23, indicated the resident was on pain medication related to cancer of left breast, chronic pain syndrome and arthritis. Interventions included, but were not limited to, administer analgesic medications as ordered.A Physician's Order, dated 4/9/24, indicated to give fentanyl transdermal patch (opioid pain medication), 50 micrograms/hour every 72 hours for pain.The November and December…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to provide routine dental services for 1 of 1 resident reviewed for Dental Services. (Resident V)Finding includes:During an interview on 1/21/26 at 10:46 a.m., Resident V indicated he had only seen the dentist once since he was admitted to the facility on [DATE]. On 1/22/26 at 9:31 a.m., Resident V's bottom lower teeth were observed to be broken and dark in color. At that time, he indicated his teeth had been breaking off, and that he wanted to see a dentist. The resident's record was reviewed on 1/23/26 at 10:36 a.m. Diagnoses included, but were not limited to, hemiplegia (paralysis on one side of the body) following a stroke, diabetes, adult failure to thrive, and need for assistance with personal care. The 12/10/25 Quarterly Minimum Data Set (MDS) indicated the resident was cognitively intact for daily decision making and was dependent in activities of daily living (ADLs) and transfers. A Physician's Order, dated 12/3/25, indicated the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to maintain clinical records that were complete and accurately documented related to incorrect documentation of medications administered for 1 of 36 records reviewed. (Resident X)Finding includes: During observation of a medication pass on 1/22/26 at 9:37 a.m., Resident X asked LPN 6 for Maalox (an anti-acid) and Miralax (a powdered laxative). LPN 6 questioned the resident which one of the medications she wanted. The resident indicated both of the medications were on her MAR (medication administration record), and that she needed both of them because they were for different problems. LPN 6 then prepared and administered Lactulose (a medication used to treat constipation or high ammonia levels) to the resident, and told her it was Miralax. The resident questioned why it was not mixed with water. LPN 6 indicated what she gave her did the same thing. The resident's record was reviewed on 1/22/26 at 2:20 p.m. Diagnoses included, but were not limited to, chronic respiratory failure, diabetes, breast cancer,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure professional standards of quality were maintained related to CNAs removing dressings to pressure ulcers and QMAs signing out wound care treatments for 3 of 3 residents reviewed for pressure ulcers. (Residents B, C, and D)Findings include:1.On 10/27/25 at 1:52 p.m., the Wound Nurse was observed providing wound care for Resident B. She prepared the supplies outside of the resident's room and donned a gown and gloves prior to entering. Upon entering the room, the resident was positioned on his right side and there was no dressing to the sacrum (a triangular bone at the base of the spine). The Wound Nurse indicated the resident had incontinence care completed prior to her entering the room. The Wound Nurse proceeded to treat the area to the sacrum. After the treatment was complete, the Wound Nurse asked for assistance from CNA 1 to complete incontinence care again around the resident's rectal tube. During an interview on 10/27/25 at 2:25 p.m., CNA 1 indicated she had provided incontinence care prior to the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure blood pressure medications were held based on parameters for 1 of 3 residents reviewed for blood pressure parameters. (Resident E) The facility also failed to ensure treatments to skin conditions non-pressure related were completed as ordered for 2 of 3 residents reviewed for pressure ulcers. (Residents D and C) Findings include: 1.The record for Resident E was reviewed on 10/28/25 at 11:13 a.m. Diagnoses included, but were not limited to, heart failure and hypertension. The 10/17/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact. A current Care Plan indicated the resident was at risk for complications secondary to the diagnosis of hypertension including altered cardiac output and ineffective tissue perfusion. Interventions included, but were not limited to, give antihypertensive medications as ordered. Physician's Orders, dated 10/2/25, indicated the resident was to receive Coreg (a blood pressure medication) 6.25 milligrams (mg) twice a day for hypertension.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure pressure ulcers treatments were completed as ordered for 3 of 3 residents reviewed for pressure ulcers. (Residents B, D, and C) Findings include:1.On 10/27/25 at 1:52 p.m., the Wound Nurse was observed providing wound care for Resident B. She prepared the supplies outside of the resident's room and donned a gown and gloves prior to entering. Upon entering the room, the resident was positioned on his right side and there was no dressing to the sacrum (a triangular bone at the base of the spine). The Wound Nurse indicated the resident had incontinence care prior to her entering the room. The Wound Nurse proceeded to clean the sacral wound with Dakin's (an antiseptic solution used to treat wounds) soaked gauze. After cleansing the wound bed, she removed her gloves, donned new gloves, and cleansed the area to the sacrum again with Dakin's soaked gauze. The Wound Nurse then applied skin prep (a protective barrier wipe) to the wound edges and packed the wound bed with Dakin's soaked kerlix gauze and applied…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure infection control guidelines were in place and implemented related to not performing hand hygiene before and after glove removal and not wearing personal protective equipment (PPE) while performing wound care for 3 of 3 residents observed for wound care. (Residents B, D, and C) Findings include: 1.On 10/27/25 at 1:52 p.m., the Wound Nurse was observed providing wound care for Resident B. She prepared the supplies outside of the resident's room and donned a gown and gloves prior to entering. She did not sanitize or wash her hands prior to donning the gloves. The Wound Nurse proceeded to clean the sacral wound with Dakin's (an antiseptic solution used to treat wounds) soaked gauze. After cleansing the wound bed, she removed her gloves and donned new gloves without hand sanitizing. She then proceeded to cleanse the wound again with Dakin's soaked gauze. The Wound Nurse then removed her gown and gloves and proceeded to the treatment cart to obtain skin prep pads. She did not sanitize her hands after…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to keep the kitchen clean and in good repair related to dirty convection ovens, transportation carts, food preparation tables, the steam table, and the reach in coolers, as well as stacking clean but wet plates and dome lids on top of each other, and improper glove usage while preparing ready to eat food for 1 of 1 kitchen. (The Main Kitchen) This had the potential to affect 154 of 155 residents who resided in the facility. Findings include: 1. During the Kitchen Sanitation Tour on 10/15/24 at 9:44 a.m., with the Food Service Manager (FSM) the following was observed: a. The sides, doors, and inside of the convection ovens were dirty with a large and heavy accumulation of grease and burned food spillage on the bottom racks. b. There was a large scoop inside the sugar bin laying directly on the sugar. c. The sides of the food preparation table and the steam table were dirty with dried food spillage. d. There were 5 open transportation carts that housed dirty trays and dishes from the units. The carts had dried…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to invite and hold care planning conferences for residents and/or their family members. The facility also failed to update a care plan related to preferences of wearing a hospital gown for 6 of 33 residents whose care plans were reviewed. (Residents 1, 9, 129, 141, 72, and 31) Findings include: 1. During random observations on 10/15/24 at 2:32 p.m., on 10/16/24 at 3:57 p.m., and on 10/17/24 at 9:49 a.m., 11:36 a.m., and 2:08 p.m., Resident 1 was observed lying in bed wearing a hospital gown. The record for Resident 1 was reviewed on 10/17/24 at 1:35 p.m. Diagnoses included, but were not limited to, multiple sclerosis, neuromuscular bladder, vascular dementia, major depressive disorder, anemia, high blood pressure, anxiety, and pain. The 8/30/24 Quarterly Minimum Data Set (MDS) assessment indicated the resident was not cognitively intact and was severely impaired for daily decision making. The resident was dependent on staff for dressing. An…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure dependent residents received ADL (Activities of Daily Living) care related to long and dirty fingernails and facial hair for 4 of 11 residents reviewed for ADL's. (Residents 1, 6, 129, and 116) Findings include: 1. During random observations on 10/15/24 at 2:32 p.m., on 10/16/24 at 3:57 p.m., on 10/17/24 at 9:49 a.m., 11:36 a.m. and 2:08 p.m., and on 10/18/24 at 9:10 a.m., Resident 1 was observed with long fingernails on both hands. The record for Resident 1 was reviewed on 10/17/24 at 1:35 p.m. Diagnoses included, but were not limited to, multiple sclerosis, neuromuscular bladder, vascular dementia, major depressive disorder, anemia, high blood pressure, anxiety, and pain. The 8/30/24 Quarterly Minimum Data Set (MDS) assessment indicated the resident was not cognitively intact and was severely impaired for daily decision making. The resident was dependent on staff for dressing, toileting, eating, personal and oral hygiene. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to correctly prepare a pureed (blended smooth) diet designed to meet the needs of the residents. This had the potential to affect 10 of 10 residents who received a pureed diet. Findings include: 1. During the pureed meal observation on 10/21/24 at 10:05 a.m., Dietary [NAME] 1 was preparing to make pureed bread for the lunch meal. At that time, there was no recipe in front of her to view. She indicated she was making enough for 15 pureed diets, however, there were only 10 residents who had orders for a pureed meal. She removed 7 slices of bread, broke them into little pieces and placed them in the blender. She poured milk from an 8 ounce carton into a measuring cup and indicated it was about 4 ounces and proceeded to pour it into the blender. She continued to add more bread and milk for a total of 27 pieces of bread and 4 (8) ounce cartons of milk to make the pureed bread. The Food Service Manager (FSM) stood by the cook during the preparation. The recipe for pureed bread, provided by the FSM, indicated the following: 10…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to keep the residents' environment clean and in good repair related to dirty floors, toilets, walls, tube feeding poles, ceiling vents, overflowing garbage cans, and debris in light fixtures. The facility also failed to keep the kitchen clean related to food splattered on walls, dirty floors, and dirty piping under the dish machine for 4 of 4 floors and 1 of 1 kitchens. (The 2nd, 3rd, 4th, 5th floors, and the main kitchen) Findings include: 1. During a random observation on 10/15/24 at 11:27 a.m., there was an overflowing garbage can that contained personal protective equipment in room [ROOM NUMBER]. Yellow isolation gowns and gloves were observed on the floor. There was 1 resident who resided in the room. 2. During an interview on 10/15/24 at 2:48 p.m., a family member indicated the room always smelled like urine and the floors were so dirty they have cleaned it themselves. They have noticed housekeeping did not clean the room every day. The resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure each resident's dignity was maintained related to being exposed from the doorway and wearing a hospital gown while in bed during the day for 3 of 6 residents reviewed for dignity. (Residents 91, 120, and 92) Findings include: 1. On 10/15/24 at 10:36 a.m., 11:10 a.m. and 3:11 p.m., Resident 91 was observed in his room seated in his wheelchair. The resident was wearing a shirt and an incontinence brief. The resident's bed was located near the door and the door to the room was open. The resident was visible from the hallway. On 10/17/24 at 10:10 a.m., the resident was again seated in his wheelchair in his room wearing a shirt and his incontinence brief. The door to the resident's room was open and he was visible from the hallway. The record for Resident 91 was reviewed on 10/17/24 at 10:36 a.m. Diagnoses included, but were not limited to, Parkinson's disease, dementia with behavior disturbance, and major depressive disorder. The Annual Minimum Data Set (MDS) assessment, dated 9/5/24, indicated the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure a comprehensive care plan was developed and in place for anti-anxiety medications for 1 of 33 resident care plans reviewed. (Resident 139) Finding includes: The record for Resident 139 was reviewed on 10/21/24 at 9:28 a.m. Diagnoses included, but were not limited to, type 2 diabetes mellitus, hypertension, and depression. The Quarterly Minimum Data Set (MDS) assessment, dated 8/23/24, indicated the resident was mildly cognitively impaired and received anti-anxiety and antipsychotic medications. A Physician's Order, dated 4/2/24, indicated the resident was to receive ABH (Ativan/Benadryl/Haldol) gel (a hospice medication for agitation) to the wrist topically two times a day for agitation and aggressive behavior. The Medication Administration Record (MAR), dated 10/2024, indicated the resident had received the ABH gel medication twice a day. There was a lack of any current care plan for the anti-anxiety medication, agitation, or aggressive behaviors. During an interview on 10/21/24 at 4:41 p.m., the Director of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure areas of bruising and scabbing were assessed and monitored, and treatments were in place for non-pressure skin injuries for 3 of 3 residents reviewed for skin conditions non-pressure related. (Residents 56, 79, and 6) Findings include: 1. On 10/15/24 at 11:07 a.m., Resident 56 was observed in his room in bed. He had an area of reddish/purple discoloration to the top of his left hand. The record for Resident 56 was reviewed on 10/18/24 at 10:30 a.m. Diagnoses included, but were not limited to, Alzheimer's disease, anemia, and type 2 diabetes. The Quarterly Minimum Data Set (MDS) assessment, dated 9/20/24, indicated the resident was cognitively impaired for daily decision making and required substantial to maximum assistance with rolling left and right and for chair to bed transfers. The resident did not have a current care plan related to the bruising to his left hand. A Weekly Skin Observation form, dated 10/17/24, indicated the resident's skin was intact and there was no documentation related to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure preventative measures were in place to prevent pressure ulcers related to the development of a new pressure area behind a resident's ear for 1 of 2 residents reviewed for pressure ulcers. (Resident 129) Finding includes: During a random observation on 10/17/24 at 2:25 p.m., Resident 129 was observed up and dressed wheeling himself down the hallway. The resident was not wearing any shoes and did not have his oxygen on. CNA 1 told the resident she would help him get something on his feet and instructed him to go back to his room. As the resident turned his wheelchair around, his left ear was observed with dried blood behind it. On 10/17/24 at 3:00 p.m., the resident was observed in his room wearing oxygen via a nasal cannula. At that time, he was asked to pull back his right ear lobe so the area behind the ear could be viewed. The area behind the ear was open with both fresh and dried blood. The resident was asked to pull back his…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure enteral tube feedings were infusing at the correct time through a peg tube (a tube inserted directly into the stomach for nutrition) for 1 of 1 resident reviewed for tube feeding. (Resident 113) Finding includes: On 10/18/24 at 9:37 a.m., Resident 113 was observed lying in bed with the head of the bed (HOB) elevated. The resident's tube feeding was running at 70 milliliter/hour (ml/hr). The tube feeding bottle was dated 10/17/24. Written on the front of the bottle with pen was a start time of 10:00 a.m., and an end time of 6:00 a.m. At 10:09 a.m., the tube feeding dated 10/17/24 was still running at 70 ml/hr. There was a new tube feeding bottle and tubing on the bedside table that was dated 10/18/24 and indicated a start time of 10:00 a.m. At 10:36 a.m., the tube feeding was shut off by QMA 1 for the resident's medication pass. At 10:47 a.m., the tube feeding bottle dated 10/18/24 was on and running at 70 ml/hr. During an interview at the time, QMA 1 indicated she had started the 10:00 a.m. tube…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure oxygen was at the correct flow rate for 1 of 1 resident reviewed for oxygen. (Resident 120) Finding includes: On 10/15/24 at 10:34 a.m. and 3:11 p.m., Resident 120 was observed in his room in bed with oxygen by the way of a nasal cannula in use. The oxygen concentrator was set at 3 liters. On 10/16/24 at 11:18 a.m., the resident was observed in his room in bed. His oxygen was in use and the oxygen concentrator was set at 3 1/2 liters. At 3:59 p.m., the oxygen concentrator was set at below 4 liters. On 10/17/24 at 10:12 a.m., 11:35 a.m. and 2:14 p.m., the resident was observed in his room in bed. His oxygen was in use and the oxygen concentrator was set at 3 1/2 liters. The record for Resident 120 was reviewed on 10/18/24 at 9:30 a.m. Diagnoses included, but were not limited to, dementia with behavior disturbance, psychotic disorder with delusions, chronic obstructive pulmonary disease (COPD), and oxygen dependent. The Quarterly Minimum Data Set (MDS) assessment, dated 7/11/24, indicated the resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure clinical records were complete and accurately documented related to medication orders for 1 of 6 residents reviewed for unnecessary medications and 1 of 1 resident reviewed for tube feeding. (Residents 139 and 113) Findings include: 1. The record for Resident 139 was reviewed on 10/21/24 at 9:28 a.m. Diagnoses included, but were not limited to, type 2 diabetes mellitus, hypertension, and depression. The Quarterly Minimum Data Set (MDS) assessment, dated 8/23/24, indicated the resident was mildly cognitively impaired and received anti-anxiety and antipsychotic medications. A Physician's Order, dated 4/2/24, indicated the resident was to receive ABH (Ativan/Benadryl/Haldol) gel (a hospice medication for agitation) to the wrist topically two times a day for agitation and aggressive behavior. There was no documented strength, dosage, or amount to give listed in the medication order. The Medication Administration Record (MAR), dated 10/2024, indicated the resident had received the ABH gel medication twice a day. There…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, and interview, the facility failed to ensure each resident received the necessary treatment and services to promote healing for pressure ulcers, related to ensuring wound care orders were updated and implemented for 1 of 3 residents reviewed for pressure ulcers. (Resident D) Finding includes: Resident D's record was reviewed on 7/2/24 at 9:42 a.m. The resident was discharged to the hospital on 5/28/24. Diagnoses included, but were not limited to, heart failure, chronic obstructive pulmonary disease, and peripheral vascular disease. The Discharge Minimum Data Set assessment, dated 5/28/24, indicated the resident was independent for decision making. She had two stage 3 pressure ulcers and two stage 4 pressure ulcers. A Care Plan, dated 3/26/24, indicated the resident had ulcers to her right heel, bilateral buttocks, and coccyx. Interventions included, but were not limited to, administer treatments as ordered and monitor for effectiveness. A Physician's Order, dated 4/11/24, indicated to cleanse right upper heel with normal saline and/or wound cleanser and apply…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure gastrostomy tube (peg tube, a tube inserted through the abdomen that allows nutrition to be delivered directly to the stomach) dietary recommendations were followed for 1 of 3 residents reviewed for peg tubes. (Resident H) Finding includes: Resident H's record was reviewed on 7/3/24 at 10:04 a.m. Diagnoses included, but were not limited to, dysphagia (difficulty swallowing), presence of gastrostomy, and aphasia (loss of ability to understand or express speech). The Discharge Minimum Data Set assessment, dated 5/16/24, indicated the resident was severely impaired for daily decision making and had a feeding tube while a resident. A Care Plan, dated 3/26/24, indicated the resident required a tube feeding. Interventions included, but were not limited to, Registered Dietician (RD) to evaluate quarterly and as needed, monitor caloric intake, estimate needs, and make recommendations for changes to the tube feeding as needed. The resident was dependent with tube feedings and water flushes. A Physician's Order, dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to properly prevent and /or contain COVID-19, related to lack of assessment and monitoring of COVID-19 positive residents, for 3 of 3 residents reviewed for infection control (Residents B, D and E). Findings include: 1. The record for Resident B was reviewed on 2/29/24 at 11:30 a.m. Diagnoses included, but were not limited to chronic obstructive pulmonary disease, Diabetes Mellitus and heart failure. The resident tested positive for COVID-19 on 1/30/24. A Physician's Order, dated 1/30/24, indicated the resident was to be placed on isolation for COVID-19 for 10 days. Health Status Notes, dated 2/1/24 and 2/6/24, indicated the resident was in isolation and noted with a cough. No shortness of breath or fever noted, vital signs were in normal limits. However there were no vital signs documented in the note. A Health Status Note, dated 2/3/24, indicated the resident was noted with some coughing and congestion. There were no Health Status Notes for 2/5, 2/7,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to serve food under sanitary conditions related to beverages being uncovered while being transported down the hallway for 1 of 1 meal observations. The facility also failed to store and prepare food under sanitary conditions related to dried spillage on the floor, walls, and door, and a build up of grease and grime on the food preparation equipment for 1 of 1 kitchens. (The Fourth Floor and the Main Kitchen) Findings include: 1. On 11/17/23 at 11:32 a.m., the beverage cart was delivered to the Fourth floor. At 11:50 a.m., a staff member was observed placing 10 styrofoam cups on the ledge of the nurses' station and filling them with juice. At 11:52 a.m., staff members were observed placing the uncovered cups on residents' lunch trays and walking down the hall. Interview with the Assistant Director of Nursing (ADON) on 11/20/23 at 3:18 p.m., indicated the cups should have been covered. The facility policy titled In-Room Dining was provided by the ADON on 11/20/23 at 3:18 p.m. and identified as current. The policy…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure dependent residents received assistance with activities of daily living (ADL's) related to nail care and shaving for 4 of 13 residents reviewed for ADL's. (Residents E, G, F, and B) Findings include: 1. On 11/15/23 at 10:15 a.m., Resident E was observed in their room in bed. A brown substance was observed underneath their fingernails on both hands. At 2:45 p.m., the resident was dressed and seated in his wheelchair in their room. The brown substance remained underneath their fingernails. On 11/16/23 at 9:22 a.m., 11:28 a.m., and 1:58 p.m., the brown substance remained underneath the resident's fingernails The record for Resident E was reviewed on 11/16/23 at 9:51 a.m. Diagnoses included, but were not limited to, stroke, dementia with other behavior disturbance, major depressive disorder, and chronic kidney disease Stage 3. The Quarterly Minimum Data Set (MDS) assessment, dated 9/11/23, indicated the resident was moderately impaired for daily decision making, required moderate assistance with personal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure areas of bruising and scabbing were assessed and monitored and lotion was applied to dry scaly feet for 8 of 9 residents reviewed for skin conditions non-pressure related. The facility also failed to ensure residents were monitored for constipation for 1 of 1 resident reviewed for constipation. (Residents N, E, K, C, G, M, J, and H) Findings include: 1. On 11/15/23 at 10:26 a.m. and 3:00 p.m., Resident N was observed in their room in bed. A fading purple bruise was observed on the top of their left hand. On 11/16/23 at 9:26 a.m. and 11:28 a.m., the bruising remained to the resident's left hand. The record for Resident N was reviewed on 11/16/23 at 2:23 p.m. Diagnoses included, but were not limited to, palliative care, dementia with behavior disturbance, and peripheral vascular disease (PVD). The Quarterly Minimum Data Set (MDS) assessment, dated 8/15/23, indicated the resident was moderately impaired for daily decision making. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure the residents' environment was clean and in good repair related to dirty floors, marred walls, loose baseboards, lime build up, missing tiles, and personal care items not contained for 4 of 5 floors throughout the facility. (The Second, Third, and Fourth floors) Findings include: During the Environmental tour with the Maintenance and Housekeeping Supervisors on 11/20/23 at 9:38 a.m., the following was observed: 1. Second Floor a. On 11/14/23 at 10:52 a.m., room [ROOM NUMBER] was observed. The floor mats were dirty, there was an accumulation of food debris on the floor in between the beds, the raised toilet seat was cracked, and the corners of the bathroom floor were dirty. The resident was currently out on hospital leave. b. The bathroom faucet in room [ROOM NUMBER] had a heavy accumulation of lime build up. There was a missing ceramic wall tile next to the toilet, and the walls were marred in the room. One resident resided in the room and 3…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure residents had Physician's Orders for medications and an assessment to self-administer their own medications for 1 of 1 residents reviewed for self-administration of medication. (Resident 146) Finding includes: On 11/16/23 at 3:10 p.m., Resident 146's room was observed. At that time, there was a box of Ivizia eye drops on the over bed table. The resident was not in her room. On 11/17/23 at 7:46 a.m., the resident was observed in bed eating breakfast. At that time, there was a box of Ivizia eye drops on the over bed table. The resident indicated she put the eye drops in her eyes when she needed them. The record for Resident 146 was reviewed on 11/16/23 at 1:25 p.m. Diagnoses included, but were not limited to, hypertensive chronic kidney disease, type 2 diabetes, end stage renal disease, dependence on renal dialysis, acute kidney failure, repeated falls, and edema. The 9/6/23 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact. The resident's vision was adequate with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to initiate Care Plans related to pressure ulcers and medication use for 2 of 33 residents whose Care Plans were reviewed. (Residents N and 12) Findings include: 1. The record for Resident N was reviewed on 11/16/23 at 2:23 p.m. Diagnoses included, but were not limited to, palliative care, dementia with behavior disturbance, and peripheral vascular disease (PVD). The Quarterly Minimum Data Set (MDS) assessment, dated 8/15/23, indicated the resident was moderately impaired for daily decision making. The resident required extensive assistance for bed mobility. The Wound Rounds Progress Notes indicated the resident had the following wounds present: - 10/30/23 Unstageable (full-thickness pressure injuries in which the base was obscured by slough and/or eschar) pressure ulcer to the right posterior upper thigh. - 10/31/23 Stage 2 (open wound) pressure ulcer to the left posterior upper thigh. - 11/10/23 Deep Tissue Injury (purple or maroon localized area of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure an Optometrist's recommendation for eye drops was completed in a timely manner for 1 of 4 residents reviewed for communication and sensory. (Resident 146) Finding includes: During an interview on 11/14/23 at 2:49 p.m., Resident 146 indicated she had seen the eye doctor and thought new glasses were ordered, but she had not received them. The record for Resident 146 was reviewed on 11/16/23 at 1:25 p.m. Diagnoses included, but were not limited to, hypertensive chronic kidney disease, type 2 diabetes, end stage renal disease, dependence on renal dialysis, acute kidney failure, repeated falls, and edema. The 9/6/23 Quarterly Minimum Data Set (MDS) assessment, indicated the resident was cognitively intact. The resident's vision was adequate with corrective lens. She had no oral problems, weighed 122 pounds, and has had a significant weight loss. The resident received dialysis as a resident. An Optometry Progress Note, dated 4/13/23, indicated the resident had mild dry eyes for both eyes. Recommend a new medication order…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure pressure ulcers were covered securely with a bandage as ordered by the Physician and treatment orders were obtained timely for new pressure sores for 2 of 4 residents reviewed for pressure ulcers. (Residents G and J) Findings include: 1. On 11/14/23 at 1:52 p.m., Resident G was observed in bed. At that time, their feet were observed laying directly on the mattress and not suspended or offloaded. The top right foot was observed with bloody scabs and the foot was bright red. There was no dressing observed. On 11/15/23 at 10:48 a.m., and 3:15 p.m., and 11/16/23 at 9:15 a.m., 1:50 p.m., the resident was observed in bed. At those times, their feet were observed laying directly on the mattress and not suspended or offloaded. The top right foot was observed with bloody scabs and the foot was bright red. On 11/17/23 at 8:04 a.m., the resident was observed in bed and their feet were laying directly on the mattress and not suspended or offloaded. There was a white bandage observed to the right foot dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure dependent residents received foot care and had routine visits with a podiatrist related to long and thick toenails for 1 of 11 residents reviewed for ADL's. (Resident G) Finding includes: On 11/14/23 1:52 p.m., on 11/15/23 at 10:48 a.m. and 3:15 p.m., on 11/16/23 at 9:15 a.m. and 1:50 p.m., and on 11/17/23 at 8:04 a.m. and 9:33 a.m., Resident G was observed in bed. At those times the resident had long thick toenails with dry scaly skin on both feet. The record for Resident G was reviewed on 11/15/23 at 3:32 p.m. Diagnoses included, but were not limited to, multiple sclerosis, vascular dementia, major depressive disorder, mood disorder, paraplegia, hammer toes for left and right feet, right foot deformity, pain in the toes, fecal impaction, constipation, and anxiety. The 9/14/23 Quarterly Minimum Data Set (MDS) assessment, indicated the resident was severely impaired for decision making and had short and long term memory problems. The resident needed extensive assist with 2 person physical assist for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure a suprapubic foley (urinary) catheter bag not on the floor and catheter care was completed as ordered by the Physician for 1 of 1 residents reviewed for catheters. (Resident 12) Finding includes: On 11/14/23 at 11:09 a.m. and 2:47 p.m., and on 11/16/23 at 9:25 a.m. and 10:15 a.m., Resident 12 was observed in bed. At those times, the foley catheter was hanging on the side of the bed, however, the bag was touching the floor. On 11/16/23 at 11:30 a.m., the resident was observed in bed. CNA 1 was asked to remove his brief to observe the stoma site of the supra pubic catheter. The area around the catheter was dark brown and crusted over. The catheter bag was observed resting on the floor. On 11/17/23 at 7:45 a.m. and 8:26 a.m., the resident was observed in bed. At that time, the foley catheter bag was observed on floor. On 11/17/23 at 8:43 a.m., RN was asked to observe the resident's supra pubic ostomy site. The RN removed the brief and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure oxygen was at the correct flow rate for 1 of 2 residents reviewed for oxygen. (Resident M) Finding includes: During an interview with Resident M on 11/14/23 at 11:48 a.m., the resident indicated they wore oxygen all the time. The oxygen flow rate was set at 2.5 liters per minute. On 11/15/23 at 10:09 a.m., and 2:30 p.m., the resident was observed wearing oxygen via nasal cannula. The oxygen flow rate was set at 3 liters per minute. The record for Resident M was reviewed on 11/16/23 at 11:03 a.m. Diagnoses included, but were not limited to, COPD (chronic obstructive pulmonary disease), anemia, chronic respiratory failure, major depressive disorder, high blood pressure, anxiety, and dependence on supplemental oxygen. The 9/29/23 Quarterly Minimum Data Set (MDS) assessment, indicated the resident was cognitively intact. The resident received oxygen as a resident and in the last 7 days she received an anticoagulant medication 7 times. A Care Plan, revised on 10/23/23, indicated the resident had oxygen…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure a dialysis resident received the correct nutritional supplement for 1 of 1 residents reviewed for dialysis. (Resident 146) Finding includes: During random observations on 11/14/23 at 2:50 p.m., 11/15/23 at 2:30 p.m., and 11/16/23 at 3:10 p.m., there was a container of Boost nutritional supplement on Resident 146's over bed table. Interview with the resident on 11/14/23 at 2:50 p.m., indicated she goes to dialysis on Tuesdays, Thursdays, and Saturdays. The Boost supplement was given to her from the nursing staff at the facility. She indicated she gets them two times a day. On 11/17/23 at 7:46 a.m., the resident was observed eating breakfast. At that time, there were 2 containers of the Boost nutritional supplement on her over bed table. The record for Resident 146 was reviewed on 11/16/23 at 1:25 p.m. Diagnoses included, but were not limited to, hypertensive chronic kidney disease, type 2 diabetes, end stage renal disease, dependence on renal dialysis, acute kidney failure, repeated falls, and edema.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to manage medications appropriately related holding blood pressure medications on dialysis days and checking blood pressure and pulse prior to the administration of blood pressure medications with Physician ordered parameters for 1 of 5 residents reviewed for unnecessary medications. (Resident 146) Finding includes: The record for Resident 146 was reviewed on 11/16/23 at 1:25 p.m. Diagnoses included, but were not limited to, hypertensive chronic kidney disease, type 2 diabetes, end stage renal disease, dependence on renal dialysis, acute kidney failure, repeated falls, and edema. The 9/6/23 Quarterly Minimum Data Set (MDS) assessment, indicated the resident was cognitively intact. The resident's vision was adequate with corrective lens. She had no oral problems, weighed 122 pounds, and has had a significant weight loss. The resident received dialysis as a resident. The Care Plan, revised on 10/27/23, indicated the resident required dialysis related to renal failure. Physician's Orders, dated 8/29/23, indicated dialysis every…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure there was an indication for the use of a psychotropic medication for 1 of 5 residents reviewed for unnecessary medications. (Resident 23) Finding includes: The record for Resident 23 was reviewed on 11/16/23 at 11:00 a.m. Diagnoses included, but were not limited to, high blood pressure, anemia, dementia, anxiety, behavior disturbance, insomnia and depression. The Quarterly Minimum Data Set (MDS) assessment, dated 9/28/23, indicated the resident was severely impaired for decision making. In the last 7 days the resident had received an antidepressant and an antipsychotic medication. A Care Plan, dated 9/28/23, indicated the resident displayed physical behavioral symptoms related to hitting a peer. Interventions included, but were not limited to, refer to psychologist/psychiatrist for behavior management as needed. A Physician's Order, dated 5/15/23, indicated for Olanzapine (antipsychotic medication) 5 milligrams(mg) be administered at bedtime related to dementia. A Nurse's Note, dated 11/3/23 at 8:18 a.m., indicated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.